by Pavitra Krishnamani
Undernutrition
he United Nations High Commissioner for Refugees (UNHCR) defines a refugee as an individual who, owing to a well-founded fear of being persecuted for race, religion, nationality, or membership of a particular social group or political opinion, is outside the country of his or her nationality and is unable or unwilling to seek the protection of that country. Refugees from diverse backgrounds are found all around the world, having given up their homes, belongings, friends and, sometimes, families to live out uncertain futures in foreign lands. In the ongoing refugee crisis, over 4 million Syrians, persecuted for their political opinion and threated by a war-torn environment, have fled from their country into the neighboring nations of Lebanon, Jordan, and Turkey. Half of these individuals were under the age of 18 and, to date, there have been over 140,000 children born as refugees. In these countries of first asylum, refugees reside in rented accommodation, housing with relatives, informal settlements, and camps. Over half of them live below national poverty lines, with the percent of Syrian refugees living in poverty rising from 50 to 70% between 2014 and 2015 in Lebanon [2]. Children, especially those from
8
resource-poor regions of the world, are particularly vulnerable to these conditions of poverty that often accompany humanitarian crises. As refugees, they are more likely to be born with a low birth weight, less likely to have access to nourishing food, and more prone to mortality due to diarrhea-inducing infectious disease processes [3,4]. Understanding that poverty-associated undernourishment challenges that begin during a humanitarian crisis continue onwards as refugees migrate to their eventual countries of resettlement, this literature review seeks to elaborate the reasons for and consequences of undernutrition in refugee children.
Nutrition in Camp Settings In protracted refugee settings, where refugees spend over 5 years in camps, inadequate nutrition and micronutrient deficiencies are usually a product of poor living conditions. Individuals in these situations often find themselves dependent on humanitarian aid, and their access to a balanced diet with adequate micronutrients is greatly hindered by decreased aid agency funding and problems in the food distribution pipeline [3]. This was the case for Bhutanese refugees of Nepali origin who fled to camps in Nepal and
India in the early 1990s. Fifteen years later, those in camps in southeastern Nepal were still reliant on food assistance. Commissioned by UNHCR and the World Food Program (WFP), a study in these camps assessed the nutritional status of Bhutanese refugee children between 6 and 59 months of age, evaluating five major health challenges of undernutrition. These included acute malnutrition, chronic malnutrition, low weight, anemia, and angular stomatitis. It found that around 4% of children had acute malnutrition, with the highest prevalence between 1 and 2 years of age [5]. This is similar to the lowest estimates in Kenyan camps hosting mostly Somali refugees in 2010 (5%) and to Syrian children in Jordan during the current crisis (5.6%) [3, 7]. The study in Nepal also found a much higher prevalence of chronic malnutrition and low weight, each of which was seen in around a quarter of refugee children. The study found that both of these were exacerbated with age, explaining why stunting is a feature commonly seen in Bhutanese refugee children even after resettlement in the United States. Riboflavin deficiency was also indicated by an increased prevalence of angular stomatitis and almost half of the children in Nepali camps had anemia, although its prevalence decreased